FNP NR511Ulrich Lisa_Week7_NR509_SOAP_Note_Template (2)-2 (1).
SOAP Note
Template
S: Subjective
Information the patient or patient representative told you
Initials: DR- 222 W. Central Phoenix, Az Age: 8 Gender: Male
87688
Height Weight BP HR RR Temp SPO2 Pain Allergie
s
90 lbs / 120/ 100 28 98.9 96% Medication: NKDA
4’2”/ 40.8 kg 76 F/ Food: NKFA
12 * 37.2 Environment: None
7cm Patien C
*Pati t
e nt report
repor s
t
s
History of Present Illness (HPI)
Chief Complaint (CC) “Been feeling sick. I have been coughing a lot. Feeling kind of tired.” CC is a BRIEF statement identifying
Onset 5 days ago, with ear pain that began yesterday. why the patient is here - in the
Location Right ear pain 3 out of 10 on pain scale, and throat pain 2 out of 10 on patient’s own words - for instance
pain scale. Nasal drainage, “My nose is always a little bit runny…but "headache", NOT "bad headache for 3
ever since I days”. Sometimes a patient has more
started coughing it’s been worse, I think.” Reports nasal drainage than one complaint. For example: If
“clear and like, water.” the patient presents with cough and
Duration Cough began 5 days ago, with ear pain and sore throat that began sore throat, identify which is the CC
yesterday. and which may be an associated
Characteristics Cough is productive. Described as “gurgly and watery.” Sputum is symptom
clear.Coughs is “every few minutes” in frequency. Cough keeps
patient from falling asleep.
Aggravating Factors No aggravating factors reported. “My cough mostly stays the same no
matter what I do. It seems to get worse at night though.”
Relieving Factors OTC cough syrup provided some temporary relief of cough. “t helped
,FNP NR511Ulrich Lisa_Week7_NR509_SOAP_Note_Template (2)-2 (1).
a bit
when my mom gave it to me, but my cough came back anyway.”
Treatment OTC cough syrup . “I don't know what the name of the cough
medicine is. It was purple.”
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Used Reason for Use
(Rx, OTC, or Homeopathic)
Cough syrup OTC name unknown unknown One dose this Cough
unknown morning
, FNP NR511Ulrich Lisa_Week7_NR509_SOAP_Note_Template (2)-2 (1).
Vitamins OTC (dinosaur Chew 2 gummies daily unknown Vitamin supplementation
gummies)
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Childhood illness: Chicken pox age 6 ½ years
Pnuemonia age 7 years
History of recurrent ear infections age 2 years
Immunizations: Immunizations up to date
Influenza vaccine: 12 months
ago Surgical history: None
Hospitalizations: None
Health maintenance/screening: Hearing screen performed at school with report of “normal hearing”
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Family status: Parents married. Lives with mother, father, and grandparents. No
siblings. Primary language English, however some Spanish is spoken in the home.
Living situation: No pets
Home clean. “Our house is always pretty clean, everyone in the family helps out to make sure the
house looks nice.” Participates/responsibilities. “ have chores I have to do, like keeping my room
SOAP Note
Template
S: Subjective
Information the patient or patient representative told you
Initials: DR- 222 W. Central Phoenix, Az Age: 8 Gender: Male
87688
Height Weight BP HR RR Temp SPO2 Pain Allergie
s
90 lbs / 120/ 100 28 98.9 96% Medication: NKDA
4’2”/ 40.8 kg 76 F/ Food: NKFA
12 * 37.2 Environment: None
7cm Patien C
*Pati t
e nt report
repor s
t
s
History of Present Illness (HPI)
Chief Complaint (CC) “Been feeling sick. I have been coughing a lot. Feeling kind of tired.” CC is a BRIEF statement identifying
Onset 5 days ago, with ear pain that began yesterday. why the patient is here - in the
Location Right ear pain 3 out of 10 on pain scale, and throat pain 2 out of 10 on patient’s own words - for instance
pain scale. Nasal drainage, “My nose is always a little bit runny…but "headache", NOT "bad headache for 3
ever since I days”. Sometimes a patient has more
started coughing it’s been worse, I think.” Reports nasal drainage than one complaint. For example: If
“clear and like, water.” the patient presents with cough and
Duration Cough began 5 days ago, with ear pain and sore throat that began sore throat, identify which is the CC
yesterday. and which may be an associated
Characteristics Cough is productive. Described as “gurgly and watery.” Sputum is symptom
clear.Coughs is “every few minutes” in frequency. Cough keeps
patient from falling asleep.
Aggravating Factors No aggravating factors reported. “My cough mostly stays the same no
matter what I do. It seems to get worse at night though.”
Relieving Factors OTC cough syrup provided some temporary relief of cough. “t helped
,FNP NR511Ulrich Lisa_Week7_NR509_SOAP_Note_Template (2)-2 (1).
a bit
when my mom gave it to me, but my cough came back anyway.”
Treatment OTC cough syrup . “I don't know what the name of the cough
medicine is. It was purple.”
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Used Reason for Use
(Rx, OTC, or Homeopathic)
Cough syrup OTC name unknown unknown One dose this Cough
unknown morning
, FNP NR511Ulrich Lisa_Week7_NR509_SOAP_Note_Template (2)-2 (1).
Vitamins OTC (dinosaur Chew 2 gummies daily unknown Vitamin supplementation
gummies)
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text. enter text. enter here
text. to enter text.
Click or tap here to enter Click or tap here to Click or tap here to Click or tap Click or tap here to enter text.
text. enter text. enter here
text. to enter text.
Click or tap here to enter Click or tap here to Click or tap here to Click or tap Click or tap here to enter text.
text. enter text. enter here
text. to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Childhood illness: Chicken pox age 6 ½ years
Pnuemonia age 7 years
History of recurrent ear infections age 2 years
Immunizations: Immunizations up to date
Influenza vaccine: 12 months
ago Surgical history: None
Hospitalizations: None
Health maintenance/screening: Hearing screen performed at school with report of “normal hearing”
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Family status: Parents married. Lives with mother, father, and grandparents. No
siblings. Primary language English, however some Spanish is spoken in the home.
Living situation: No pets
Home clean. “Our house is always pretty clean, everyone in the family helps out to make sure the
house looks nice.” Participates/responsibilities. “ have chores I have to do, like keeping my room
